Monday, December 17, 2007

The high jacking or corruption of EBM

The following quote is taken from DBs Medical Rants which he quotes from a BMJ article which apparently requires a subscription so I can't access it but it so good I have to feature it here.Evidence based care was never meant to be a substitute for clinical judgment but, combined with the inducements of the quality and outcomes framework, it becomes so. Mechanistic blanket management strategies, embedded into computer software, become fixed and static with the danger that innovation will be stifled. Interventions become routine, and practitioners are no longer required to grapple with the innate uncertainty of each different clinical situation. Most randomised trials systematically exclude patients’ symptoms, functional status, comorbidity, severity of illness, ideas, and preferences. Yet these are the factors which should fundamentally affect decisions about appropriate treatment.2 Within large study populations, there will be smaller populations sharing different characteristics whose response to a given treatment will differ from that of the larger group. Such groups could be systematically harmed by the intervention, and there are currently no robust systems in place to measure or monitor this.3

The "insight/word" ratio is that paragraph is about as high as it can get.

Not only will innovation be stifled, individualized, proper thoughtful patient care will be worse than stifled it could almost die out. Of course with blanket management strategies, or pathways or algorithms or recipes patients could be harmed. And the innate uncertainty of each different clinical situation is what it is all about.Two patients with chest pain often have different underlying diseases, two patient with the same disease label have different symptoms, two patients treated with the same dose of the same medication for the allegedly same disease have greatly different responses,two patients with the same disease label react differently to the suggestion that they even take a medication.In a given randomized clinical trial some patients get much better, some a little better, some not at all and some get worse.

The lure of the mantra of evidence based pathways or guidelines is exactly what third party payers can use in their rational quest to control physicians to control costs to control their profit stream. Control is the operative word. Recognition of this innate uncertainty is the last thing they want to admit to or deal with.

The lure of the mantra of evidence based pathways and guidelines works well for the academics and others who "partner" with the third party payers to control the working stiff docs in their rational quest to be members of the ruling class , to be first among equals , to be the animals that are more equal that the others or for whatever reason they have.

The lure of the mantra of evidence based medicine (EBM) fits nicely with those whose philosophical mind set includes the notion that medicine is too important to be left to the individual physician and the individual patient and that wiser heads must prevail so that people will do the right things for themselves.

The lure of evidence based medicine could not be better for some drug companies whose skilled epidemiologists and statisticians are able to stack the deck and cook the books to make the overworked, over regulated, over hassled physician in her quest to do the right thing for her patients believe that their latest entry into the medication market is clearly what she should prescribe yesterday whether that is true or not. It should be said that deck stacking and book cooking is not the monopoly of drug companies but are the seductive tools of anyone with an ax to grind.

The lure of evidence based medicine even offers apparent salvation for the over worked, over regulated, over hassled physician who sometimes thinks "Hell, just tell me what to do, give me the latest guidelines."

The lure of evidence based could not be better for the third payers who would decrease payments generally and then reward these compliant with the guidelines with part of the money they took away.

The lure of evidence based medicine could not be better for the newly minted MPH who can now crank out a meta analysis or a quick and dirty case-control study with software that is so much easier to run than to understand that can flash across the rapidly cycling news cycle, bag an interview and add to their CV, whether the study makes sense or not.

The lure of evidence based guidelines could not be better for those believe the way to go is the mid-level route. Arm a NP or PA with electronic access to the right guidelines for efficient, evidence based care and then only the complicated cases would need the physician's input and I suppose the guidelines would include guidance as to when a case is complicated.

The manipulative value of the evidence based medicine label has meant so much to so many that it has become harder and harder to separate the valuable contributions of valid, well done clinical trials and analytic thought from the hijacked, counterfeit versions that serve to control the narrative dialog and ultimately to control much more. Reference to EBM can serve as a talisman.To say that such and so is evidence based is to ignore the real question which is what is the nature of the evidence.

In hospital practice, if your colleagues actually combined analytic thought based on the patient's status with evidence based medicine we might see a decrease in costs, iatrogenic sequela, and law suits. If only....